Upgrading Therapy Strategy Improves Pregnancy Outcome in Antiphospholipid Syndrome: A Cohort Management Study

The current study evaluates the efficacy and safety of different treatment strategies for pregnant patients with antiphospholipid syndrome. One hundred twenty-seven consecutive pregnancies were assessed; 87 (68.5%) with a history of pregnancy morbidity alone were treated with prophylactic low molecular weight heparin (LMWH) + low-dose aspirin (LDA, 100 mg) (group I) and 40 (31.5%) with a history of thrombosis and/or severe pregnancy complications with therapeutic LMWH + LDA (group II). LMWH doses were increased throughout the pregnancies depending on the patients' weight gain, and treatment was switched to a more intensive one at the first sign of maternal/fetal complications. The study's primary outcome was live births. There were no significant differences in live birth rate between group I (95.4%) and group II (87.5%). Even fetal complication rate was similar in the two groups; group II nevertheless had a higher prevalence of maternal and neonatal complications (p = 0.0005 and p = 0.01, respectively) and registered a significantly lower gestational age at delivery and birth weight (p = 0.0001 and p = 0.0005, respectively). Two patients in group I switched to group II therapy, six patients in group II switched to a more intensive treatment strategy (weekly plasma exchange + fortnightly intravenous immunoglobulins in addition to therapeutic LMWH + LDA). The multivariate analysis uncovered that triple antiphospholipid antibodies positivity was an independent factor leading to a more intensive therapy. All eight switched patients achieved a live birth. Study results revealed that adjusted LMWH doses and switching therapy at first signs of severe pregnancy complications led to a high rate of live births in antiphospholipid syndrome patients

Prognostic significance of high-grade dysplasia in colorectal adenomas.

Aim  Colonoscopy to detect and remove polyps has contributed to a reduction in colorectal carcinoma. Three-year follow up is recommended for patients considered to be at high risk (at least three adenomas, adenoma ≥ 1 cm, villous or high-grade features). Our study focused on patients diagnosed with high-grade dysplasia with regard to initial management and follow up. Method  A search of patients who had had endoscopic removal of a high-grade adenoma was carried out. Patients with the following were excluded: follow up of \u3c 1 year, polyposis syndromes, prior colon cancer and a diagnosis of adenocarcinoma within 6 months following initial diagnosis. Results  Eighty-three patients treated between 1999 and 2007 for high-grade dysplasia (HGD) in a colorectal adenoma were identified. Over a median follow-up period of 4 years, 53 (64%) developed further adenomatous polyps. Among these, 7% had an adenoma with HGD or an adenocarcinoma. In all these patients, the initial high-grade adenoma was \u3e 1 cm in diameter. Initial follow-up colonoscopy was performed on average 7 months following the initial diagnosis. Ten per cent of patients underwent prophylactic segmental resection, and 6% received argon laser therapy. Conclusion  The study demonstrates that patients who have a colorectal adenoma \u3e 1 cm with HGD may be at high risk of developing further adenomas with HGD or carcinoma. Close follow up is warranted

AB0378 UPGRADING THERAPY STRATEGY IMPROVES PREGNANCY OUTCOME IN ANTIPHOSPHOLIPID SYNDROME: A COHORT MANAGEMENT STUDY

Background:While it is generally agreed that pregnant APS patients should receive personalized treatment, evidence-based guidelines for these patients continue to be lacking.Objectives:The current study was designed as a management cohort study aiming to evaluate the efficacy and safety of different treatment strategies for pregnant APS patients in the attempt to provide some practical suggestions for attending physicians.Methods:One-hundred-twenty-seven consecutive pregnancies were assessed; 87 (68.5%) with a history of pregnancy morbidity alone were treated with prophylactic low molecular weight heparin (LMWH)+low-dose aspirin (LDA, 100 mg) [Group I] and 40 (31.5%) with a history of thrombosis and/or severe pregnancy complications with therapeutic LMWH+LDA [Group II]. LMWH doses were increased throughout the pregnancies depending on the patients' weight gain, and treatment was switched to a more intensive one at the first sign of maternal/fetal complications. The study's primary outcome was live births.Results:There were no significant differences in live birth rate between Group I (95.4%) and Group II (87.5%). Even, fetal complication rate was similar in the two groups; the Group II nevertheless had a higher prevalence of maternal and neonatal complications (p=0.0005 and p=0.01, respectively) and registered a significantly lower gestational age at delivery and birth weight (p=0.0001 and p=0.0005, respectively). Two patients in Group I switched to Group II therapy, six patients in Group II switched to a more intensive treatment strategy (weekly plasma exchange+ fortnightly intravenous immunoglobulins in addition to therapeutic LMWH+LDA). Comparison of the clinical and laboratory characteristics between patients who had shifted to a more intensive therapy and those who did not showed a significant prevalence of history of thrombosis ± pregnancy morbidity (p=0.02, OR 5.96, 95% CI 1.33-26.62) previous pregnancy complications (p=0.02, OR 8.32, 95% CI 1.67-41.3), triple aPL positivity (p <0.0001, OR 97.13, 95% CI 10.6-890) and pregnancy complications (p<0.0001, OR 197,7, 95% CI 10.57-3699) in upgrading group, instead single aPL positivity significantly prevailed (p=0.003, OR 0.06, 95% CI 0.008-0.58) in non-upgrading group. Logistic regression analysis demonstrated that triple aPL positivity was an independent factor for switching to a more effective therapy protocol (p <0.0001, OR 98, 95% CI 10.7-897.54). All eight switched patients achieved a live birth.Conclusion:Using adjusted LMWH doses and upgrading therapy at the first signs of pregnancy complications led to a high rate of live births in a relatively large group of APS patients. The study outlines the criteria for prescribing appropriate therapy for various subsets of these patients and for switching/upgrading the treatment protocol when it is no longer sufficient. Unfortunately, for the moment there are no evidence-based guidelines on the ideal additional treatment in refractory to conventional therapy APS patients. The present results will hopefully help point the direction of future clinical trials investigating the efficacy and safety of the different therapies on large numbers of APS pregnant patients in order to identify the benefits and limits of different treatment strategies administered from the beginning of pregnancy.Disclosure of Interests:Ariela Hoxha Speakers bureau: Celgene, UCB, Novartis, Sanofi, Werfen, Maria Favaro: None declared, Antonia Calligaro: None declared, Teresa Del Ross: None declared, Alessandra Teresa Ruffatti: None declared, Chiara Infantolino: None declared, Marta Tonello: None declared, Elena Mattia: None declared, Amelia Ruffatti: None declare

Quality of life following radiofrequency ablation of dysplastic Barrett’s esophagus

The impact of the diagnosis and treatment of dysplastic Barrett’s esophagus (BE) on quality of life (QoL) is poorly understood. This study assessed the influence of dysplastic BE on QoL and evaluated if endoscopic treatment of dysplastic BE with radiofrequency ablation (RFA) improves QoL

Human limb skeletal muscle wasting and architectural remodeling during five to ten days intubation and ventilation in critical care - an observational study using ultrasound

© 2016 The Author(s).Background: Critically ill patients frequently suffer muscle weakness whilst in critical care. Ultrasound can reliably track loss of muscle size, but also quantifies the arrangement of the muscle fascicles, known as the muscle architecture. We sought to measure both pennation angle and fascicle length, as well as tracking changes in muscle thickness in a population of critically ill patients. Methods: On days 1, 5 and 10 after admission to critical care, muscle thickness was measured in ventilated critically ill patients using bedside ultrasound. Elbow flexor compartment, medial head of gastrocnemius and vastus lateralis muscle were investigated. In the lower limb, we determined the pennation angle to derive the fascicle length. Results: We recruited and scanned 22 patients on day 1 after admission to critical care, 16 were re-scanned on day 5 and 9 on day 10. We found no changes to the size of the elbow flexor compartment over 10days of admission. In the gastrocnemius, there were no significant changes to muscle thickness or pennation angle over 5 or 10days. In the vastus lateralis, we found significant losses in both muscle thickness and pennation angle on day 5, but found that fascicle length is unchanged. Loss of muscle on day 5 was related to decreases in pennation angle. In both lower limb muscles, a positive relationship was observed between the pennation angle on day 1, and the percentage of angle lost by days 5 and 10. Discussion: Muscle loss in critically ill patients preferentially affects the lower limb, possibly due to the lower limb becoming prone to disuse atrophy. Muscle architecture of the thigh changes in the first 5days of admission, in particular, we have demonstrated a correlation between muscle thickness and pennation angle. It is hypothesised that weakness in the lower limb occurs through loss of force generation via a reduced pennation angle. Conclusion: Using ultrasound, we have been able to demonstrate that muscle thickness and architecture of vastus lateralisundergo rapid changes during the early phase of admission to a critical care environment

Durability of Radiofrequency Ablation in Barrett's Esophagus With Dysplasia

Radiofrequency ablation (RFA) can eradicate dysplasia and intestinal metaplasia in patients with dysplastic Barrett’s esophagus (BE), and reduce rates of esophageal adenocarcinoma. We assessed long-term rates of eradication, durability of neosquamous epithelium, disease progression, and safety of RFA in patients with dysplastic BE

TTV infection in patients with acute hepatitis of defined aetiology and in acute non-A-E hepatitis

Background/Aims: Recently, the presence of a novel nonenveloped single-stranded DNA virus (TTV) has been associated with either acute or chronic hepatitis of unknown aetiology, suggesting a possible aetiological role. The aim of this study was to evaluate the prevalence, the significance and the clinical impact of TTV infection in patients with acute viral hepatitis of defined aetiology and in patients with non-A-E acute hepatitis. Methods: TTV-DNA was tested by hemi-nested PCR in serum samples collected from 121 patients during and after acute hepatitis (103 with acute viral hepatitis of defined aetiology and 18 with acute non-A-E hepatitis) and in 30 healthy controls. Results: Overall, the rate of TTV infection was 12.6% (13/103) in patients with acute hepatitis of defined aetiology, 16.6% (3/18) in patients with non-A-E acute hepatitis and 6.6% (2/30) in the healthy control group, (p=n.s). TTV-DNA was detected in the following proportions: hepatitis B, 13.2% (7/53); hepatitis C, 16.6% (4/24); hepatitis A, 4.7% (1/21); hepatitis E 20% (1/5). Moreover, acute hepatitis with and without TTV infection/coinfection were comparable in terms of both liver biochemistry and chronicity rate. The results of TTV re-testing after serial dilutions of six TTV-DNA positive serum samples during and after the peak of liver transaminases failed to demonstrate a correlation between liver damage and viral titre. Conclusions: The prevalence of TTV infection appeared to be comparable in patients with non-A-E hepatitis, in acute hepatitis of defined aetiology and in the control group. Hence, an aetiological role of TTV for acute hepatitis of unknown aetiology seems questionable. Moreover, TTV infection does not modify the natural history of acute hepatitis of defined aetiology

Pregnancy and primary biliary cirrhosis: A case\u2013control study

Although very old papers reported a supposed alterations in sexual hormones, there are no specific reports on pregnancy in PBC. Aim: To analyze fertility in PBC and to investigate the outcome of pregnancy and the influence of pregnancy on the disease course. Methods: 233 consecutive female patients with PBC were included in the study (mean age at diagnosis of 52.9\ub112 years). Among them, 186 had at least one conception and were matched with a 1:2 group of 367 healthywomenwith at least one conception in their life. Results: There were 507 pregnancies in PBC patients and 700 in controls (mean average 1.91 vs. 2.73, p < 0.05). The life history in terms of miscarriages, voluntary interruption of pregnancy, term and preterm delivery was similar in the two groups. The number of caesarean deliveries was lower in PBC patients than in controls (8.6% vs. 15.5%, p < 0.05). Perinatal and postnatal death and child birth complications were observed only in the PBC patients (total number of babies = 11 [2.7%]). Pruritus during pregnancy was recorded in 13 patients with PBC (3.0% of total pregnancies) and in none of the control subjects. The risk of pruritus in PBC was associated to the advanced disease (stage III\u2013IV: OR 78, 95% CI 5.55\u20131108.61, p < 0.05). The risk of miscarriage, corrected for age at pregnancy and number of previous miscarriages, was inversely associated with the histological stage (I\u2013II: OR 0.32, 95% CI 0.10\u20130.97, p < 0.05). Eight pregnancies occurred after the diagnosis of PBC in 6 patients (two of them with histological stage IV). All pregnancies had a favorable course at term; ursodeoxycholic acid was continued and no worsening of the disease was observed. Conclusions: Successful completion of pregnancy is a realistic expectation for PBC patients; monitoring of pregnancy and delivery, however, is required due a potential risk of child birth complications